Rachana Pradham, KFF Health News

Hundreds of workers at the National Institutes of Health on Monday openly protested the Trump administration’s cuts to the agency and consequences for human lives, writing in a sharply worded letter that its actions are causing “a dramatic reduction in life-saving research.”

In a June 9 letter to NIH Director Jay Bhattacharya, NIH workers said they felt “compelled to speak up when our leadership prioritizes political momentum over human safety and faithful stewardship of public resources.”

“For staff across the National Institutes of Health (NIH), we dissent to Administration policies that undermine the NIH mission, waste public resources, and harm the health of Americans and people across the globe,” they said.

The letter is an extraordinary rebuke of the Trump administration’s actions against the NIH, which include: terminating hundreds of grants funding scientific and biomedical research; firing more than 1,000 employees this year; and moving to end billions in funds to partner institutions overseas, a move current and former NIH workers say will harm research on rare cancers and infectious diseases, as well as research that aims to minimize tobacco use and related chronic illnesses, among other areas.

Some NIH workers signed their names publicly, openly daring to challenge a president who has sought to purge the government of employees he views as disloyal to him. Others signed anonymously.

KFF Health News has asked officials from the NIH and the Department of Health and Human Services, which oversees NIH, for comment.

“It’s about the harm that these policies are having on research participants and American public health, and global public health,” said Jenna Norton, who works at the National Institute of Diabetes and Digestive and Kidney Diseases, one of NIH’s 27 institutes. “There are research participants who generously decide to donate their time and literal pieces of their body, with the understanding that that service is going to help advance research for diseases that they are living with and help the next person who comes along with that disease.”

“These policies are preventing us from delivering on the promise we made to them and honoring the commitment that they made, and putting them at risk,” she said.

The workers wrote that they hope Bhattacharya welcomes their criticisms given his vows to prioritize “academic freedom” and to respect dissenting views as leader of the NIH, which is based in Bethesda, Maryland. Its authors called it the “Bethesda Declaration” — a play on the controversial “Great Barrington Declaration” that Bhattacharya co-authored during the covid-19 pandemic.

Bhattacharya’s declaration advocated against lockdown measures and proposed that widespread immunity against covid could be achieved by allowing healthy people to get infected with the virus and instituting protective measures only for medically vulnerable people. It was criticized at the time by Francis Collins, then-director of the NIH, who called Bhattacharya and his co-authors “fringe epidemiologists,” according to emails the American Institute for Economic Research obtained through a Freedom of Information Act request.

In their letter, NIH workers demanded that Bhattacharya restore grants that were “delayed or terminated for political reasons.” Those grants funded a range of projects, including those addressing Alzheimer’s disease, ways to boost vaccination rates, and efforts to combat health disparities or health misinformation.

“Academic freedom should not be applied selectively based on political ideology. To achieve political aims, NIH has targeted multiple universities with indiscriminate grant terminations, payment freezes for ongoing research, and blanket holds on awards regardless of the quality, progress, or impact of the science,” the NIH workers wrote.

The funding terminations, they said, “throw away years of hard work and millions of dollars,” “risk participant health,” and “damage hard-earned public trust, counter to your stated goal to improve trust in NIH.”

The NIH’s nearly $48 billion budget makes it the world’s largest public funder of scientific research. Its work has led to countless scientific discoveries that have helped improve health and save lives around the globe. But it hasn’t been without controversies, including instances of research misconduct and not effectively monitoring grant awards and the related research.

Researchers and some states have sued NIH and HHS over the grant cuts. An April 3 deposition by NIH official Michelle Bulls said Rachel Riley, a senior adviser at HHS who is part of the Department of Government Efficiency created by executive order, provided NIH officials lists of grants to terminate and language for termination notices. Elon Musk, the world’s richest person, led DOGE through May.

Norton has worked at the NIH as a federal employee or contractor for about a decade. She said the current administration’s policies are “definitely unethical and very likely illegal,” listing a string of developments in recent months. They include terminating studies early and putting participating patients at risk because they have had to abruptly stop taking medications, and holding up research that would predominantly or exclusively recruit participants from minority races and ethnicities, who have historically been underrepresented in medical research.

“They’re saying that doing studies exclusively on Black Americans to try to develop interventions that work for that population, or interventions that are culturally tailored to Hispanic-Latino populations — that that kind of research can’t go forward is extremely problematic,” Norton said. “And, as a matter of fact, studies that over-recruit from white people have been allowed to go forward.”

The NIH workers also demanded that Bhattacharya reinstate workers who were dismissed under recent mass firings and allow research that is done in partnership with institutions in foreign countries “to continue without disruption.” The NIH works with organizations around the globe to combat major public health issues, including types of cancer, tobacco-related illnesses, and HIV.

In addition to the firing of probationary workers, NIH fired 1,200 civil servants as part of a rapid “reduction in force” at federal health agencies. During a May 19 town hall meeting with NIH staff, a recording of which was obtained by KFF Health News, Bhattacharya said the decisions about RIFs “happened before I got here. I actually don’t have any transparency into how those decisions were made.”

He started at NIH on April 1, the day many workers at NIH and other agencies were told they were fired. Other workers have been fired since Bhattacharya took the helm — nearly all the National Cancer Institute’s communications staff were fired in early May, three former employees told KFF Health News.

The letter is the latest salvo in a growing movement by scientists and others against the Trump administration’s actions. In addition to in-person protests outside HHS headquarters and elsewhere, some former employees are organizing patients to get involved.

Peter Garrett, who led the National Cancer Institute’s communications work, has created an advocacy nonprofit called Patient Action for Cancer Research. The aim is to engage patients “in the conversation and federal funding and science policymaking,” he said in an interview.

His group aims to get patients and their relatives to speak out about how federal cancer research affects them directly, he said — a “guerrilla lobbying” effort to put the issue squarely before members of Congress. Garrett said he retired early from the cancer institute because of concerns about political interference.

Career officials routinely work under both Republican and Democratic presidents. It is par for the course for their priorities and assignments to evolve when a new president, Cabinet secretaries, and other political appointees take over. Usually, those changes occur without much protest.

This time, workers said the upheaval and harm done to the NIH is so extensive that they felt they had no choice but to protest.

In 11 years at NIH, Norton said, “I’ve never seen anything that comes anywhere near this.”

In the June 9 letter, the workers said, “Many have raised these concerns to NIH leadership, yet we remain pressured to implement harmful measures.”

“It’s not about our jobs,” said one NIH worker who signed the letter anonymously. “It is about humanity. It is about the future.”

The National Institutes of Health employee said she knew things would be difficult for federal workers after Donald Trump was elected. But she never imagined it would be like this.

Focused on Alzheimer’s and other dementia research, the worker is among thousands who abruptly lost their jobs in the Trump administration’s federal workforce purge. The way she was terminated — in February through a boilerplate notice alleging poor performance, something she pointedly said was “not true” — made her feel she was “losing hope in humans.”

She said she can’t focus or meditate, and can barely go to the gym. At the urging of her therapist, she made an appointment with a psychiatrist in March after she felt she’d “hit the bottom,” she said.

“I am going through hell,” said the employee, who worked at the National Institute on Aging, one of 27 centers that make up the NIH. The worker, like others interviewed for this story, was granted anonymity because of the fear of professional retaliation.

“I know I am a mother. I am a wife. But I am also a person who was very happy with her career,” she said. “They took my job and my life from my hands without any reason.”

President Trump and his allies have increasingly denigrated the roughly 2 million people who make up the federal workforce, 80% of whom work outside the Washington, D.C., area. Trump has said federal workers are “destroying this country,” called them “crooked” and “dishonest,” and insinuated that they’re lazy. “Many of them don’t work at all,” he said earlier this month.

Elon Musk — who is the world’s richest person and whose Department of Government Efficiency, created by a Trump executive order, is infiltrating federal agencies and spearheading mass firings — has claimed without evidence that “there are a number of people on the government payroll who are dead” and others “who are not real people.” At a conference for conservatives in February, Musk brandished what he called “the chain saw for bureaucracy” and said that “waste is pretty much everywhere.”

The firings that began in February are taking a significant toll on federal employees’ mental health. Workers said they feel overwhelmed and demoralized, have obtained or considered seeking psychiatric care and medication, and feel anxious about being able to pay bills or afford college for their children.

Federal employees are bracing for more layoffs after agencies were required to deliver plans by this month for large-scale staff reductions. Compounding the uncertainty: After judges ruled that some initial firings were illegal, agencies have rehired some workers and placed others on paid administrative leave. Then, Trump on March 20 issued a memo giving the Office of Personnel Management more power to fire people across agencies.

Researchers who study job loss say these mass layoffs not only are disrupting the lives of tens of thousands of federal workers but also will reverberate out to their spouses, children, and communities.

“I’d expect this will have long-lasting impacts on these people’s lives and those around them,” said Jennie Brand, a professor of sociology at UCLA who wrote a paper about the implications of job loss. “We can see this impact years down the road.”

Studies have shown that people who are unemployed experience greater anxiety, depression, and suicide risk. The longer the period of unemployment, the worse the effects.

Couples fight more when one person loses a job, and if it’s a man, divorce rates increase.

Children with an unemployed parent are more likely to do poorly in school, repeat a grade, or drop out. It can even affect whether they go to college, Brand said. There’s an “intergenerational impact of instability,” she said.

And it doesn’t stop there. When people lose their jobs, especially when it’s many people at once, the wealth and resources available in their community are reduced. Kids see fewer employed role models. As families are forced to move, neighborhood stability gets upended. Unemployed people often withdraw from social and civic life, avoiding community gatherings, church, or other places where they might have to discuss or explain their job loss.

Although getting a new job can alleviate some of these problems, it doesn’t eliminate them, Brand said.

“It’s not as if people just get new jobs and then pick up the activities they used to be involved with,” she said. “There’s not a quick recovery.”

Slashing Cultural Norms

The firings are upending a long-standing norm of the public sector — in exchange for earning less money compared with private-sector work, people had greater job security and more generous benefits. Now that’s no longer the case, fired workers said in interviews.

With the American economy moving toward temporary and gig jobs, landing a traditional government job was supposed to be “like you’ve got the golden goose,” said Blake Allan, a professor of counseling psychology at the University of Houston who researches how the quality of work affects people’s lives.

Even federal workers who are still employed face the daily question of whether they’ll be fired next. That constant state of insecurity, Allan said, can create chronic stress, which is linked to anxiety, depression, digestive problems, heart disease, and a host of other health issues.

One employee at the Centers for Medicare & Medicaid Services, who was granted anonymity to avoid professional retaliation, said the administration’s actions seem designed to cause enough emotional distress that workers voluntarily leave. “I feel like this ax will always be over my head for as long as I’m here and this administration is here,” the employee said.

Federal workers who passed on higher-paying private sector jobs because they wanted to serve their country may feel especially gutted to hear Trump and Musk denigrate their work as wasteful.

“Work is such a fundamental part of our identity,” Allan said. When it’s suddenly lost, “it can be really devastating to your sense of purpose and identity, your sense of social mattering, especially when it’s in a climate of devaluing what you do.”

Andrew Hazelton, a scientist in Florida, was working on improving hurricane forecasts when he was fired in February from the National Oceanic and Atmospheric Administration. The mass firings were carried out “with no humanity,” he said. “And that’s really tough.”

Hazelton became a federal employee in October but had worked alongside NOAA scientists for over eight years, including as an employee at the University of Miami. He lost his job as part of a purge targeting probationary workers, who lack civil service protections against firings.

His friends set up a GoFundMe crowdfunding page to provide a financial cushion for him, his wife, and their four children. Then in March, after a federal judge’s order requiring federal agencies to rescind those terminations, he was notified that he had been reinstated on paid administrative leave.

“It’s created a lot of instability,” said Hazelton, who still isn’t being allowed to do his work. “We just want to serve the public and get our forecasts and our data out there to help people make decisions, regardless of politics.”

Health Coverage Collateral

Along with their jobs, many federal workers are losing their health insurance, leaving them ill equipped to seek care just as they and their families are facing a tidal wave of potential mental and physical health consequences. And the nation’s mental health system is already underfunded, understaffed, and overstretched. Even with insurance, many people wait weeks or months to receive care.

“Most people don’t have a bunch of money sitting around to spend on therapy when you need to cover your mortgage for a couple months and try to find a different job,” Allan said.

A second NIH worker considered talking to a psychiatrist and potentially going on an antidepressant because of anxiety after being fired in February.

“And then the first thought after that was: ‘Oh, I’m about to not have insurance. I can’t do that,’” said the worker, who was granted anonymity to avoid professional retaliation. The worker’s health benefits were set to end in April — leaving too little time to get an appointment with a psychiatrist, let alone start a prescription.

“I don’t want to go on something and then have to stop it immediately,” the worker said.

The employee, one of several NIH workers reinstated this month, still fears getting fired again. The worker focuses on Alzheimer’s and related dementias and was inspired to join the agency because a grandmother has the disease.

The worker worries that “decades of research are going to be gone and people are going to be left with nothing.”

“I go from anxiety to deep sadness when I think about my own family,” the employee said.

The NIH, with its $47 billion annual budget, is the largest public funder of biomedical research in the world. The agency awarded nearly 59,000 grants in fiscal 2023, but the Trump administration has begun canceling hundreds of grants on research topics that new political appointees oppose, including vaccine hesitancy and the health of LGBTQ+ populations.

The NIH worker who worked at the National Institute on Aging was informed in mid-March that she would be on paid administrative leave “until further notice.” She said she is not sure whether she would find a similar job, adding that she “cannot be at home doing nothing.”

Apart from loving her job, she said, she has one child in college and another in high school and needs stable income. “I don’t know what I’m going to do next.”

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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A federal lawsuit in Texas against Planned Parenthood has a web of ties to conservative activist Leonard Leo, whose decades-long effort to steer the U.S. court system to the right overturned Roe vs. Wade, yielding the biggest rollback of reproductive health access in half a century.

Brought by an anonymous whistleblower and later joined by Texas Attorney General Ken Paxton, the suit alleges the Planned Parenthood Federation of America and three Planned Parenthood affiliates defrauded the Texas and Louisiana Medicaid programs by collecting $17 million for services provided while it fought state efforts to remove it as an approved provider.

The suit claims violations of the False Claims Act, an obscure but powerful law protecting the government from fraud, and seeks $1.8 billion in penalties from Planned Parenthood, according to a motion that lawyers for the whistleblower filed in federal court in 2023.

The lawsuit builds on efforts over years by the religious right and politicians who oppose abortion to deliver blows to Planned Parenthood — which provides sexual and reproductive health care at nearly 600 sites nationwide — now bolstered by Leo’s work reshaping the American judiciary.

Anti-abortion groups and their allies secured a generational victory in 2022 when the Supreme Court overturned Roe vs. Wade, which ended the constitutional right to abortion and paved the way for bans or severe restrictions in 20 states. The court challenge in Texas demonstrates how the forces behind the end of Roe threaten access to other health and family planning services.

The Planned Parenthood clinics being sued do not provide abortions. They are in Texas and Louisiana, which banned nearly all abortions, respectively, in 2021 and 2022.

Leo, an anti-abortion Catholic, is connected to the key players in the Texas lawsuit — the whistleblower plaintiff, an attorney general, and the judge — according to a KFF Health News review of tax records, court documents from multiple lawsuits, statements to lawmakers, and website archives.

Leo provided legal counsel to the anti-abortion group at its center, and he has financial and other connections to Paxton.

They filed the case in federal court in Amarillo, Texas, where Matthew Kacsmaryk is the only judge. He is a longtime member of the Federalist Society, the conservative legal juggernaut for which Leo has worked for over 25 years in various capacities and currently serves as co-chair.

Kacsmaryk’s rulings have curtailed access to reproductive health since the Senate confirmed him in 2019. He suspended the FDA’s approval of mifepristone, a drug used in medication abortion, propelling the issue to the Supreme Court, which ultimately threw out the case. In another case, Kacsmaryk ruled to limit young people’s access to birth control through a federal family planning program.

Leo did not respond to questions for this article and a spokesperson declined to comment. Through a court spokesperson, Kacsmaryk declined to comment for this article.

The anonymous whistleblower in 2021 accused the Planned Parenthood Federation of America and Planned Parenthood affiliates of defrauding the Medicaid programs of Texas and Louisiana. Paxton, who has repeatedly acted to thwart abortion rights and joined the case in 2022, alleges in the lawsuit that clinics received payments they weren’t entitled to from Texas Medicaid from early 2017 to early 2021 as the state was pushing to end Planned Parenthood’s status as a Medicaid provider. Louisiana and the Department of Justice have not joined the complaint.

The lawsuit’s origins go back a decade. The anonymous whistleblower, between 2013 and 2015, “conducted an undercover investigation to determine whether Planned Parenthood’s fetal tissue procurement practices were continuing, and if they were legal and/or ethical,” according to the whistleblower’s complaint filed in 2021.

The explanation mimics how the Center for Medical Progress, a California-based anti-abortion group founded by activist David Daleiden in 2013, has publicly described its work. “The Human Capital project is a 30-month-long investigative journalism study by The Center for Medical Progress, documenting how Planned Parenthood sells the body parts of aborted babies,” the group states on its website.

In a November 2022 court order, Kacsmaryk said the private party initiating the lawsuit is “the president of CMP,” the title Daleiden held at that time, according to a Center for Medical Progress tax filing.

The Center for Medical Progress and Daleiden did not respond to requests for comment.

By law, federal funds can’t pay for abortions unless the pregnancy threatens the life of a woman or is the result of rape or incest, but the program reimburses for other care such as contraception, screenings for sexually transmitted infections, and cancer screenings. Medicaid, which provides health coverage for people with low incomes, is jointly financed by states and the federal government.

According to its 2022-23 annual report, Planned Parenthood affiliate clinics provided 9.13 million health care services to 2.05 million patients nationally in 2022. Testing and treatment for sexually transmitted infections accounted for about half of those services, contraception amounted to a quarter, and abortions constituted 4%.

Planned Parenthood Gulf Coast, which operates clinics in Texas and Louisiana, is among the branches Paxton and the whistleblower are suing. From July 2022 to June 2023, its clinics provided patients more than 86,000 tests for sexually transmitted infections, 44,000 visits for birth control, and nearly 7,000 cancer screening and prevention services, CEO Melaney Linton told KFF Health News.

“All of these services and more are at risk in this politically motivated lawsuit,” Linton said. The lawsuit’s allegations “are false. Planned Parenthood did not commit Medicaid fraud.”

Linton has said the lawsuit’s purpose is clear: “trying to shut Planned Parenthood down.”

Texas terminated Planned Parenthood’s Medicaid participation in March 2021. Until then, affiliates “were entitled to receive reimbursement” for services to Medicaid patients because their provider agreements with Texas’ Medicaid program were valid, attorneys for the Planned Parenthood clinics wrote in a February 2023 court filing in support of their motion for summary judgment.

Louisiana has not removed Planned Parenthood from its Medicaid program.

Leo served as legal counsel to the Center for Medical Progress, according to documents produced as part of a separate lawsuit Planned Parenthood filed in federal court in California against the anti-abortion group. Among those, a July 2018 document lists 25 emails Leo and Daleiden traded in June and July 2015, including in the days before the anti-abortion group released its first video.

Paxton’s ties to Leo can be traced back at least a decade to when the former state senator and rising conservative star was about to begin his first term as attorney general.

In 2014, Leo, then executive vice president of the Federalist Society, was a rare non-Texan named to Paxton’s attorney general transition advisory team. Tax filings show that the Concord Fund, one of several Leo-linked groups that spend money to influence elections and aren’t required to disclose their donors, gave $20.3 million from July 2014 through June 2023 to the Republican Attorneys General Association, the political nonprofit that works to elect Republicans as states’ top law enforcement officers. Known as RAGA, the group funneled more than $1.2 million to Paxton’s campaign over three election cycles from 2014 to 2022, Texas campaign finance records show.

Texas government officials knew the state was reimbursing Planned Parenthood clinics for medical services from 2017 to 2021, which renders the state’s argument that clinics violated the False Claims Act “without merit,” said Jacob Elberg, a professor at Seton Hall Law School and an expert in health care fraud.

The law is intended for situations “where essentially someone submits a claim for payment or keeps money that they’re not entitled to where they have information that the government doesn’t have,” Elberg said. “And they essentially know that if the government knew the truth, the government wouldn’t pay them or would be demanding money back.”

But with Planned Parenthood, “everything involved here happened out in the open,” Elberg said. “They were submitting bills and the government knew what was going on and was paying those bills.”

The plaintiffs’ arguments are a “tortured use” of the False Claims Act, said Sarah Saldaña, a former U.S. attorney for the Northern District of Texas.

“Things like this, which have these obvious political overtones, tend to undermine further the view of the public of the judicial courts system,” Saldaña said.

The office of the attorney general did not respond to requests for comment.

Anti-abortion groups support the Paxton lawsuit even though abortion is essentially outlawed in the Lone Star State. Planned Parenthood “is still a pro-abortion organization,” said John Seago, president of Texas Right to Life. Even though Planned Parenthood provides other care, “all of those services are tainted by their pro-abortion mindset,” he said.

“Planned Parenthood is a danger to Texans. We wish that Planned Parenthood didn’t have a single location within our state,” Seago said. “Whenever the state pays Planned Parenthood to do something, even if it’s a good service, we are building up their brand and giving them more reach into our Texas communities.”

Roughly three dozen Planned Parenthood clinics in Texas continue to provide non-abortion services like birth control and STI screenings. The $1.8 billion the whistleblower is seeking is equivalent to nearly 90% of Planned Parenthood’s annual revenue, according to its most recent annual report.

The Campaign Against Planned Parenthood

The Center for Medical Progress was little known in 2015 when it began releasing videos containing explosive allegations that Planned Parenthood was illegally selling tissue from aborted fetuses, which Planned Parenthood denies.

The group and Daleiden had ties to powerful anti-abortion organizations. They include Live Action, where Daleiden worked before creating the Center for Medical Progress, and Operation Rescue, the Kansas-based group that staged demonstrations against George Tiller’s abortion clinic in that state before a gunman killed the physician in 2009.

“The evidence I am gathering deeply implicates Planned Parenthood affiliates across the country in multiple felonies and can trigger severe legal and financial consequences for PP and their associates, while providing new justifications for state defunding efforts and turning public opinion against Planned Parenthood and abortion,” Daleiden wrote in a May 2013 email produced as part of the litigation Planned Parenthood brought in California. The subject line: “Meeting to Take Down PP.”

Texas tried to remove Planned Parenthood clinics from its Medicaid program following the center’s release of the undercover videos, a move that was part of a larger political firestorm. Roughly a dozen states launched investigations into the reproductive health provider, and Republicans in Congress renewed calls to strip Planned Parenthood of government funding.

Paxton made his feelings clear about abortion as he pursued an investigation of Planned Parenthood in Texas. During a July 29, 2015, legislative hearing, he said “the true abomination in all of this is the institution of abortion.”

“We are rightfully horrified by what we’ve seen on these videos,” Paxton said. “However these videos also serve as a larger reminder that, as a society, we’ve turned a blind eye to the gruesome horrors that occur in abortion clinics across America every single day. They remind us that this industry as a whole has lost the perspective of humanity.”

Planned Parenthood denied selling fetal tissue and other claims in the videos, some of which contained graphic footage. It said the videos were “deceptive” and heavily edited to be misleading. A grand jury in Texas cleared Planned Parenthood of wrongdoing.

Daleiden worked on the center’s “Human Capital Project” for years, receiving advice from Leo and his associates, according to the Center for Medical Progress’ website, and Daleiden’s email correspondence and other documents produced as part of the separate lawsuit in federal court in California.

The July 2018 document filed as part of the litigation in California describes emails between Leo and Daleiden as “providing legal communication with counsel regarding legal planning” and “for counsel to provide legal advice regarding investigative journalism methods and the legality of fetal tissue procurement practices,” among other descriptions. Daleiden sent one email to Leo “regarding legal planning” on July 13, 2015, the day before the Center for Medical Progress released its first video.

A November 2018 letter from the Center for Medical Progress’ lawyers stated “CMP was receiving legal advice” from Leo, as well as other conservative lawyers and organizations. Lawyers representing the center and Daleiden in a December 2018 legal filing said Leo “provided legal advice on how to ensure successful prosecutions of the criminal actors which CMP identified.”

In its defense, Planned Parenthood has said it billed the Texas Medicaid program for reimbursement for “ lawfully provided” services from February 2017 to March 2021 as a participating Medicaid provider in the state.

In 2015 and 2017, federal courts in Louisiana and Texas blocked those states from terminating Planned Parenthood’s Medicaid provider agreements. Judge John deGravelles of the U.S. District Court for the Middle District of Louisiana said the state was prohibited “from suspending Medicaid payments to (Planned Parenthood Gulf Coast) for services rendered to Medicaid beneficiaries.”

The 5th Circuit Court of Appeals in November 2020 vacated the Texas and Louisiana injunctions, but the court never weighed in on clawing back Medicaid funds that had been paid to clinics. Texas terminated Planned Parenthood in March 2021, following a state court ruling.

Texas and the whistleblower argue that, once the court injunctions were lifted, Planned Parenthood’s termination from each state’s Medicaid program became effective years earlier — 2015 in Louisiana and 2017 in Texas — due to the dates that state officials gave clinics final notice.

Planned Parenthood has argued that it is under no obligation to return payments received while injunctions were in place. Kacsmaryk disagrees. In a recently unsealed summary judgment order in the case, the judge wrote that Planned Parenthood clinics “had an obligation to repay the government payments they received as a matter of law.”

The order was unsealed after attorneys for the Reporters Committee for Freedom of the Press intervened. The committee argued the public has a presumptive and constitutional right to access judicial records, and that Kacsmaryk’s stated concerns — which included the tainting of a potential jury pool or jeopardizing the safety of those involved in the lawsuit — didn’t justify keeping the document secret.

Kacsmaryk’s brief justification for sealing the document, contained in the order itself, “was very thin,” said Katie Townsend, legal director for the Reporters Committee for Freedom of the Press.

She said his decision to seal such an important document was “highly unusual” and “very troubling.”

“Those orders are almost always completely public,” she said.

What Paxton Gains

Paxton has publicly toyed with the idea of pursuing federal office, and former President Donald Trump has said he’d consider him for U.S. attorney general should Trump return to the White House.

For Republicans in Texas, there are political benefits to going after Planned Parenthood, said Mark Jones, a political scientist at Rice University in Houston. “Doing anything punitive against Planned Parenthood and anything that would reduce the ability of Planned Parenthood to be active and effective in Texas is going to be greeted with near-universal consensus within the Republican primary electorate,” Jones said. “There’s no downside to it.”

The Republican Attorneys General Association, which can accept unlimited political donations that it distributes to candidates, is a Paxton supporter. Campaign finance records show it gave more than $730,000 to Paxton’s attorney general campaigns in 2014 and 2018.

Tax filings show that the Marble Freedom Trust, a political nonprofit where Leo serves as trustee and chair, gave the Concord Fund $100.9 million from May 2020 through April 2023. During the 2022 election cycle, the Concord Fund gave $6.5 million to RAGA, which then contributed $500,000 to Paxton’s campaign. It was tied as the highest contribution to the Texas attorney general, matched by a $500,000 contribution from a political action committee backed by conservative Texas billionaires, according to Transparency USA, a nonprofit that tracks spending in state politics.

RAGA has praised Leo’s role, calling him its “greatest champion.”

“Leonard Leo has helped shape the trajectory of RAGA and the conservative legal movement more than anyone else. As RAGA’s greatest champion, Leonard Leo reimagined the role of the state attorney general and promoted men and women dedicated to the persistence of the rule of law and the original meaning of the Constitution,” reads a RAGA website post from 2019 that has since been deleted.

“You want access to Leo because Leo gives you access to money,” said Chris Toth, former executive director of the National Association of Attorneys General.

In many conservative states like Texas, Toth said, “the issue is worrying about getting primaried. And that is where playing nice with Leonard Leo and the Concord Fund come in because if you’re on their side, basically, you’re going to have no problem gettingreelected.”

The Concord Fund gave $4 million to RAGA between July 1, 2022, and June 30, 2023, four times what it gave the prior fiscal year.

Abortion rights supporters have warned that they anticipate ongoing reproductive health battles in Texas and beyond, with access to contraception, fertility services, and other types of care under threat.

As an example, some point to the Griswold vs. Connecticut decision from 1965, in which the Supreme Court legalized the use of contraception among married couples. The high court ruled that a state law violated a constitutional right to privacy, a rationale that was central to Roe vs. Wad e eight years later.

In a 2017 speech at the Acton Institute, a conservative think tank, Leo criticized Griswold as a decision amounting to “the creation of rights found nowhere in the text or structure of the Constitution.”

The Planned Parenthood lawsuit in Texas is expected to go to trial, potentially this year. The central question is whether Planned Parenthood knowingly withheld money owed to the government.

All the while the public is expressing greater uncertainty about rights once considered constitutionally guaranteed. In a KFF poll conducted in February, 1 in 5 adults said the right to use contraception is threatened and likely to be overturned.

Fewer than half of adults considered it to be secure.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.